Curiosare tra le raccomandazioni delle nuove linee guida sulla ... · Raccomandazioni dei BB (2006)...

PL. TemporelliFondazione Salvatore Maugeri, IRCCS, Fondazione Salvatore Maugeri, IRCCS,

Divisione di Cardiologia Riabilitativa, VerunoDivisione di Cardiologia Riabilitativa, Veruno

Curiosare tra le raccomandazioni delle nuove linee guida sulla cardiopatia

ischemica cronica

Spectrum of IHDFihn SD et al. JACC 2012;60:e44-e164

“Non hai veramente

capito qualcosa finché

non sei in grado di

spiegarlo a tua nonna”

Albert Einstein

Ischemia

Popolazione

generale

Coronaropatia

Pregresso IMA,

pregressa PTCA,

pregresso CABG

Angina

“Cardiopatia Ischemica Cronica”

Prognosi a 1 anno in prevenzione primaria e nella cardiopatia ischemica acuta o cronica

Diagnosis of stable ischemic heart disease

« The clinical examination is the key first step in

evaluating patients with chest pain and should

include a detailed assessment of symptoms…»

Fihn SD et al. JACC 2012;60:e44-e164

Pretest Likelihood of CAD in Symptomatic Patients

According to Age and Sex* (Combined Diamond/Forrester

and CASS Data)

Likelihood increases according to the presence of hypertension, smoking,

hypercholesterolemia and diabetes

High > 85%

Intermediate 15-85%

Low < 15%

Pretest likelihood of CAD in patients with suspected CAD

ESC Guidelines. Eur Heart J 2013; 34: 2949-3003

Risk Assessment in stable CAD

The Challenge

� - To indicate wich patients with CAD are

at risk for coronary events

� - To treat those patients only, in a manner

that reduces the risk of an event

Non-invasive testing in patients with suspected SCAD and an intermediate pre-test probability


Stress testing in patients with stable angina who require noninvasive

testing


Standard exercise ECG testing is recommended for patients with an intermediate pretest probability of IHD who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity.

I IIa IIb III

I IIa IIb III

Able to Exercise

Exercise stress with nuclear MPI or echocardiography is recommended for patients with an intermediate to high pretest probability of IHD who have an uninterpretable ECG and at least moderate physical functioning or no disabling comorbidity.

Pharmacological stress with nuclear MPI, echocardiography, or CMR is not recommended for patients who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity.

I IIa IIb III

No Benefit

Able to Exercise (cont.)

I IIa IIb III

No Benefit

Exercise stress with nuclear MPI is not recommended as an initial test in low-risk patients who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity.

Appropriateness of stress imaging in a large academic cardiology practice

SPECT ECHO

Gibbons et al. JACC 2008; 51: 1283-9

n=284 n=298

The top five inappropriate indications

INDICATION PERCENT

Detection of CAD

Asymptomatic, low CHD risk

46%

Asymptomatic, post-revascularization

< 2 years after PCI

25%

Evaluation of chest pain, low probability pt

Interpretable ECG and able to exercise

16%

Asymptomatic or stable symptoms

< 1 year after cath or abnormal prior SPECT

4%


Coronary angiography is not recommended to assess risk in patients who are at low risk according to clinical criteria and who have not undergone noninvasive risk testing.

I IIaIIb III

No Benefit

Coronary Angiography to Assess Risk After

Initial Workup With Noninvasive Testing

Lin GA JAMA 2008;300:1765-1773

Con quale frequenza viene eseguito un test provocativo di ischemia in un paziente

candidato a PCI elettiva?

Analisi retrospettiva effettuata all’interno di un

campione di 23887 pazienti, estratto dal

sistema Medicare del 2004:

10629 (44.5%) furono sottoposti alla esecuzione

di test per la documentazione di ischemia nei 90 gg precedenti la PCI

Hachamovitch R et al. Circulation 2003;107:2900–7

Benefit of revascularization in terms of survival is proportional to the amount of ischaemia

10 627 patients

pp=0.001=0.001

Rates of death or MI by ischemia reduction in subset of 105 patients with

moderate-to-severe pre-Rx ischemia

(n=68) (n=37)

32.4%

16.2%

Dea

th o

r M

I rat

e (%

)

Relationship between cardiac mortality and extent of ischemia

Risk Assessment in stable CAD

E allora ?

Acute PCI

� 355.417 (71.1%)

� 98.6% appropriate

� 0.3 % uncertain

� 1.1 % inappropriate

Non-acute PCI

� 144.737 (28.9%)

� 50.4% appropriate

� 38.0% uncertain

� 11.6% inappropriate

Appropriateness of Percutaneous

Coronary Intervention

JAMA, July 6, 2011—Vol 306, No. 1

Patients within the National Cardiovascular Data Registry

undergoing PCI between July 1, 2009, and September 30, 2010,

at 1091 US hospitals.

Coronary angiography is not recommended to assess risk in patients who are at low risk according to clinical criteria and who have not undergone noninvasive risk testing.

I IIaIIb III

No Benefit



I IIaIIb III

No Benefit

Coronary angiography is not recommended to assess risk in asymptomatic patients with no evidence of ischemia on noninvasive testing.

The Heart Team

Medical management of patients with stable coronary artery disease.


Sintomi Prognosi

1 A

Raccomandazioni dei BB (2006)

1 A angina e post-IM

1 B angina senza IM

Sintomi Prognosi

1 A

Raccomandazioni dei BB (2013)

Fig. 4, Pag. 35

β-bloccanti nella SCAD: confronto L.G. ESC 2006 vs 2013

� In stable CAD the debate should not be medical vs. revascularization therapy but rather which patients should be offered revascularization and when.

� PCI of specific stenotic lesions relieves angina more than medical treatment alone, but it does not change atherosclerosis in the rest of the vasculature.

Summary (i)

�Given the existing medical evidence, optimal medical therapy should be the foundation in the management of pts with stable CAD.

�“Medical therapy” today no longer means the absence of revascularisation, but rather the presence of intensive, evidence-based pharmacologic and lifestyle interventions.

�Recent guidelines reinforces the role of new antianginal agents.

Summary (ii)

Key Guideline Messages

• The relatively small proportion of patients who have “high-risk” anatomy (e.g., >50% stenosis of the left main coronary artery), revascularization of with CABG should be considered to potentially improve survival. Most data showing improved survival with surgery compared to medical therapy are several decades old and based on surgical techniques and medical therapies that have advanced considerably. There are no conclusive data demonstrating improved survival following PCI.

ACC/AHA Chronic Angina Guidelines:

Basic Treatment / Education

The initial treatment of the patient should include all elements:

A.A. Aspirin and Antianginal therapy

B.B. Beta blocker and Blood pressure

C.C. Cigarette smoking and Cholesterol

D.D. Diet and Diabetes

E.E. Education and Exercise

ACC/AHA 2007 Guideline Update

for the Management of Patients with Chronic Stable Angina


• Patients with SIHD should generally receive a “package”of GDMT that include lifestyle interventions and medications shown to improve outcomes which includes (as appropriate):– Diet, weight loss and regular physical activity;– If a smoker, smoking cessation;– Aspirin 75-162mg daily;– A statin medication in moderate dosage;– If hypertensive, antihypertensive medication to achieve a BP

<140/90; If diabetic, appropriate glycemic control.

Anti-ischemic Strategies in Ischemic Stable Heart Disease

Initial therapy

Persistent/Recurrent ischemia

↑↑↑↑ Antianginal drug therapy(uptitrate/add additional

agents)

Repeat revascularization (if possible)

Drug therapy PCI CABG

Freedom from angina in trials comparing a routine invasive with an initial non-

invasive strategy in stable CAD

Simoons ML and Windecker S Eur Heart J 2010; 31; 530–541

Ranolazine in combination with beta blockers can be useful when prescribed for relief of symptoms when initial treatment with beta blockers is not successful in patients with SIHD.

I IIaIIb III

Use of Anti-Ischemic Medications

Ranolazine can be useful when prescribed as a substitute for beta blockers for relief of symptoms in patients with SIHD if initial treatment with beta blockers leads to unacceptable side effects or is ineffective or if initial treatment with beta blockers is contraindicated.

I IIaIIb III

Patients with SIHD should receive periodic follow-up, at least annually, that includes all of the following:a.Assessment of symptoms and clinical function;b.Surveillance for complications of SIHD, including heart failure and arrhythmias;c.Monitoring of cardiac risk factors; andd.Assessment of the adequacy of and adherence to recommended lifestyle changes and medical therapy.

I IIaIIb III

Periodic Follow-Up

I IIaIIb III Assessment of LVEF and segmental wall motion by echocardiography or radionuclide imaging is recommended in patients with new or worsening heart failure or evidence of intervening MI by history or ECG.

In patients who have no new or worsening symptoms or no prior evidence of silent ischemia and are not at high risk for a recurrent cardiac event, the usefulness of annual surveillance exercise ECG testing is not well established.

I IIaIIb III

I IIaIIb III

Noninvasive Testing in Known

SIHD—Asymptomatic

(or Stable Symptoms)

Nuclear MPI, echocardiography, or CMR, with either exercise or pharmacological stress or CCTA, is not recommended for follow-up assessment in patients with SIHD, if performed more frequently than at a) 5-year intervals after CABG or b) 2-year intervals after PCI.

Conferme

Risk Assessment in CAD

The Challenge

� - To indicate wich patients with CAD

are at risk for coronary events

� - To treat those patients in a manner that

reduces the risk of an event

Stress testing in patients with stable angina

who require noninvasive testing

54


Appropriateness of stress imaging in a large academic cardiology practice

SPECT ECHO


n=284 n=298

The top five

inappropriate indications

INDICATION PERCENT

Detection of CAD


46%


< 2 years after PCI

25%



16%



4%



• The relatively small proportion of patients who have “high-risk” anatomy (e.g., >50% stenosis of the left main coronary artery), revascularization of with CABG should be considered to potentially improve survival. Most data showing improved survival with surgery compared to medical therapy are several decades old and based on surgical techniques and medical therapies that have advanced considerably. There are no conclusive data demonstrating improved survival following PCI.

Coronary arteriography is recommended for patients with SIHD whose clinical characteristics and results of noninvasive testing indicate a high likelihood of severe IHD and when the benefits are deemed to exceed risk.

Coronary angiography is reasonable to further assess risk in patients with SIHD who have depressed LV function (EF <50%) and moderate risk criteria on noninvasive testing with demonstrable ischemia.

I IIaIIb III



I IIaIIb III

Coronary angiography is reasonable to further assess risk in patients with SIHD and inconclusive prognostic information after noninvasive testing or in patients for whom noninvasive testing is contraindicated or inadequate.

Coronary angiography for risk assessment is reasonable for patients with SIHD who have unsatisfactory quality of life due to angina, have preserved LV function (EF >50%), and have intermediate risk criteria on noninvasive testing.

I IIaIIb III



(cont.)

I IIaIIb III

Coronary angiography for risk assessment is not recommended in patients with SIHD who elect not to undergo revascularization or who are not candidates for revascularization because of comorbidities or individual preferences .

Coronary angiography is not recommended to further assess risk in patients with SIHD who have preserved LV function (EF >50%) and low-risk criteria on noninvasive testing.

I IIaIIb III

No Benefit



(cont.)

I IIaIIb III

No Benefit

“Cardiopatia Ischemica Cronica”Definizione

1. Pazienti sintomatici con possibile Angina Pectoris stabile da sforzo, o suoi equivalenti

2. Pazienti asintomatici, ma con evidenza clinico-strumentale di pregresso Infarto Miocardico (da oltre 6 mesi)

2. Pazienti asintomatici, ma portatori di patologia ostruttiva coronarica accertata (ad es. pazienti già sottoposti a PCI o CABG) (da oltre 6 mesi)

ACP Clinical Guideline, Ann Intern Med 2004; 141: 562

ACC/AHA Guideline, J Am Coll Cardiol, 2003; 41:159

Continuità assistenziale

post-dimissione

NSTEMI

(n=2912)

STEMI

(n=2833)

Counseling infermieristico

710 (26.4%) 741 (28.5%)

Percorso prevenzione

388 (14.5%) 562 (21.6%)

Riabilitazione cardiologica

213 (7.3%) 325 (12%)

Percorso fumo 95 (3.3%) 174 (6.1%)

Percorso obesi 94 (3.3%) 106 (3.7%)

Percorso diabete 93 (3.2%) 86 (3.0%)

Joint ESC Guidelines. Eur Heart J 2012, May 3

• Maggiori “input” dalla medicina generale e dal nursing

• Maggiore enfasi al controllo degli stili di vita in prevenzione primaria e secondaria

• Analisi più dettagliata dei limiti dei sistemi di “grading” dell’evidenza

• Ri-definizione delle priorità e degli obiettivi

• Revisione dell’approccio al rischio nei soggetti giovani

• Aggiornamento delle sezioni sui “fattori di rischio classici”

• Nuove sezioni dedicate ai “nuovi fattori di rischio”

Percentage of the Decrease in Deaths from CHD

Attributed to Treatments and Risk-Factor Changes

Ford ES et al. N Engl J Med 2007; 356:2388

The use of revascularization for chronic angina resulted in a reduction of approximately 15,690 deaths in 2000, as compared with deaths in 1980, or approximately

5% of the total and only 1.3% was

attributable to PCI.

The Centers for Disease Control

Secondary Prevention As a Multifactorial Approach and Comprehensive Long-term

Services

�Optimized therapy

�Risk stratification

�Risk factors modification

�Counseling and behavioural interventions

�Follow-up

ESC Guidelines, Eur Heart J, 2006;27:1341-1381

Comprehensive Medical Therapy For Patients with CHD or Other Vascular Disease

Risk Reduction

� ASA 20-30%

� Beta Blockers 20-35%

� ACE inhibitors 22-25%

� Statins 25-42%

The four medications every atherosclerosis patient should be treated with, unless contraindications exist and are documented

AHA/ACC Guidelines. Circulation 2006

Ivabradine reduces primary end point in angina patients

n=1507P=0.05

Years

0

5

10

15

20

0 0.5 1 1.5 2

Cum

ulat

ive

inci

denc

efo

r P

EP

* (

%)

--24%24%Placebo

IvabradineIvabradine

Primary end point (PEP) : CV death + hospitalizatio n for HF or MI

Fox K, Ford I, et al; BEAUTIFUL Investigators. Effect of ivabradine on cardiovascular outcomes in patients with

stable coronary artery diseaseand left-ventricular systolic dysfunction with limiting angina: a subgroup

analysis of the randomized, controlled BEAUTIFUL trial. Eur heart Jour On line.

Effects of Ranolazine on Recurrent

Cardiovascular Events After ACS

Recurrent Ischemia (%)

Days from Randomization

Ranolazine 17.3%

(N=3,279)

Placebo 20.0%

(N=3,281)

HR 0.87 (95% CI 0.76 o 0.99)

P =0.030

0.0

00

.05

0.1

00

.15

0.2

00

.25

0 180 360 540

Mehta HR et al. Circulation 2005;112:II-793

Medication ComplianceCRUSADE Registry (1-Year)

Interruzione delle “evidence-based medical therapies” e prognosi dopo IMA:

dati del Registro PREMIER

Ho PM, et al. Arch Intern Med. 2006;166:1842-1847

HR

� “A total of 46.2% of the patients in the clopidogrel group

discontinued the study medication temporarily (for more than five

days), as compared with 45.4% in the placebo group”

�“The overall tolerability of prasugrel was comparable to

clopidogrel as demonstrated by a similar incidence of study drug

discontinuation between treatment groups (17.91% vs 17.32%,

p=NS).”

THE TRITON TIMI 38 TRIAL Prasugrel - FDA Advisory Committee Breafing

Document, Jan 2009

�“Premature discontinuation in 23.4% of pts in the ticagrelor

group vs 21.5% of pts in the clopidogrel group (p=0.002)”

THE PLATO TRIAL Wallentin L et al. NEJM 2009; 361: 1045-57

Discontinuation of Clopidogrel, Prasugrel and Ticagrelor

in CURE, TRITON and PLATO

Discontinuation of Clopidogrel, Prasugrel and Ticagrelor

in CURE, TRITON and PLATO

THE CURE TRIAL N Engl J Med 2001;345:494-502

Medication NonadherenceMedication Nonadherence

Baroletti S, Dell'Orfano H. Circulation. 2010;121:1455-8


Services





�Follow-up


Algorithm for inizial evaluation of patients with stable angina

SI

Duke Treadmill Score

NO

Basso

Follow-Up Clinico

Medio

Stress Imagingsede / estensione / vitalità

-

Follow-Up Clinico

+

Coronarografia

Alto

Stratificazione del rischio nellStratificazione del rischio nell’’Angina StabileAngina Stabile

Incapacita’

esercizio

WPW

PM

BBS

segni di scompenso

valvulopatia nuova o in deterioramento

Ecocardiografia

basale

Prognostic Role of Exercise Testing

in Chronic CAD Mark DB et al. N Engl J Med, 1991;325:849-53

Appropriateness in a large academic cardiology practice

64,0%11,0%

14,0%

11,0%

AppropriateUncertainInappropriateUnclassified

64,0%9,0%

18,0%

9,0%

SPECT ECHOSPECT ECHO


n=284 n=284 n=298n=298

The top five inappropriate indications

INDICATION PERCENT

Detection of CAD


46%


< 2 years after PCI

25%



16%



4%


Hachamovitch R et al. Circulation 2003;107:2900–7

Benefit of revascularization in terms of survival is

proportional to the amount of ischaemia

10 627 patients

Frequency of Stress Testing to Document

Ischemia Prior to Elective PCI

Lin GA et al. JAMA 2008;300:1765-1773

Medicare BICS

44.5%

24%

EuroHeart

Survey

Sirtax BASKET Leaders BICS OSCAR

Italian Survey

PCI for Stable CAD in Recent All-comers

Trials and Registries in Europe

Coronarografia sistematica

-in pazienti affetti da angina tipica stabile e/o ad alto rischio di CAD dopo un test provocativo (per la prognosi e per la scelta terapeutica)

Coronarografia selettiva

-in coloro per i quali il rischio di malattia rimane “intermedio” dopo l’esecuzione di un test

provocativo (ai fini diagnostici)

Coronarografia sistematica o selettiva nella cardiopatia ischemica cronica?

Zoran Olivari, ANMCO 2012Zoran Olivari, ANMCO 2012

Coronarografia

≠

PCI

Coronarografia sistematica o selettiva nella cardiopatia ischemica cronica?

Zoran Olivari, ANMCO 2012Zoran Olivari, ANMCO 2012


Services





�Follow-up


EUROASPIRE II Study Group

� Il 15% dei fumatori non erano stati informati sulla

necessità di smettere di fumare;

�Alla dimissione solo nel 31% delle relazioni erano

riportate informazioni relative alla attività fisica;

� Il 43% dei malati in sovrappeso non erano stati

informati sulla necessità di ridurre il peso;

� Istruzioni sull’alimentazione erano state fornite al

33% degli ipertesi ed al 61% dei dislipidemici

Cohen, Lancet 2001; 357

Management of Stable Coronary Disease

A 65-year old man with hypertension, obesity, and type 2 diabetes who presented with a 2-week history of exertional angina. He underwent an exercise SPECT which showed a fixed anterior defect and a reversible anterolateral defect, both of moderate size. His subsequent cardiac catheterization revealed an occluded first diagonal branch, a long lesion with 70% stenosis in the midportion of the LAD, a calcified lesion with 80% stenosis in the proximal circ, and 50% stenosis of the PDA. These findings were accompanied by anterior-wall hypokinesis and an EF of 45% by left ventriculography.

N Engl J Med. 2007;357(17):1762-1766

Treatment Option 1Appropriate Medical Management

and Close Follow-up for Adherence and Efficacy

Salim Yusuf, and

Ernest Fallen,

Treatment Option 2Appropriate Medical

Management and PCI

Robert A. Harrington

Treatment Option 3Appropriate Medical

Management and CABG

Robert A. Guyton

Management of Stable Coronary Disease Polling Results

Cheng S and Jarcho J. N Engl J Med 2007;357:e28

Management of Stable Coronary Disease Polling Results

Wallentin L et al. Lancet 2000;356:9–16

Juul-Moller S et al. Lancet 1992;340:1421–1425

Shepherd J et al. N Engl J Med 1995;333:1301–1307

Mor

te/IM

A n

on fa

tale

(%

)

Follow-up (mesi)

Angina instabile/ IMA non Q (FRISC II)

16

12

8

4

0

0 2 4 6 8 10 12

Angina stabile (SAPAT)

Prevenzione primaria (WOSCOPS)

Prognosi nel paziente in prevenzione primaria e con cardiopatia ischemica acuta o cronica

Burden of Stable Angina in the US

� 9.1 million American adults have chronic angina 1

� 500,000 new cases diagnosed per year� 50% experience angina as the initial sign of ischem ic

heart disease� 213 per 100,000 annual US angina incidence in

people >30 years of age� ~50% of patients presenting with MI at the hospital

have preceding angina 2

� > 25% of patients experience angina up to five year s post-PCI with optimal medical care 3

1 Rosamond W, et al. Heart Disease and Stroke Statistics – 2008 Update. Circulation. 2008;117:e25-e146.2 Gibbons RJ, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina. p5

Available at: http://acc.org/qualityandscience/clinical/guidelines/stable/stable_clean.pdf3 Boden WE, et al. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. N Engl J Med 2007;356:1510.

Stress Echocardiography after PCIACC/AHA 2003 Guidelines

Class I

Identification of restenosis in patients with atypical recurrent symptoms

Class IIa

Assessment of restenosis in patients with typical symptoms

Class III

Routine assessment of asymptomatic patients

Cheitlin et al, ACC/AHA Guidelines 2003

Cardiac Nuclear Imaging after PCI: ACC/AHA 2003 Guidelines

Class IIa

Stress myocardial perfusion SPECT

at 3 to 5 months after PCI in

selected, high-risk * asymptomatic

patients

Klocke et al, ACC/AHA Guidelines 2003Klocke et al, ACC/AHA Guidelines 2003

* * IVA prox, multivaso, procedure complicate, IVA prox, multivaso, procedure complicate, stent multipli, diabete, disfunzione ventricolarestent multipli, diabete, disfunzione ventricolare

Evaluating Appropriateness forCardiac Radionuclide Imaging

N=6351N=6351

ACCF/United Healthcare SPECT Pilot Study

Zona Grigia

21%

• ~ 10 million European adults have chronic angina

• 53% of patients with angiographically proven coronary artery disease originally present with sta ble angina 1

• 1 year after diagnosis, 22% have undergone PCI 2

• > 25% of patients experience angina up to 5 years post-PCI with optimal medical care 3

1Lenzen MJ, et al. Management and outcome of patients with established coronary artery disease: the Euro Heart Survey on coronary revascularization. Eur Heart J 2005;26:1169-79. 2Daly C, et al. The impact of guideline compliant medical therapy on clinical outcome in patients with stable angina: findings from the Euro Heart Survey of stable angina. Eur Heart J 2006;27:1298-304. 3Boden WE, et al. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. N Engl J Med 2007;356:1510.

Burden of Stable Angina in Europe

Angina Prevalence One Year Post-MI

• Design− PREMIER (Prospective R egistry E valuating M yocardial

Infarction: E vents and R ecovery) Registry*− Multi-center prospective cohort study

� Objective− Designed to identify patient and treatment factors as sociated

with the prevalence of angina one year post-myocardia l infarction (MI)

• Primary Endpoint− Presence of angina 1 year post-MI hospitalization

� Measured by the Seattle Angina Questionnaire (SAQ)

* Study supported in part by the NIH

Maddox TM, Reid KJ, Spertus JA, et al. Arch Intern Med. 2008;168:1310-1316

• Results (n = 1957)− ~ 1 in 5 patients had angina 1 year post-MI

−Of these, ~ 1 in 5 had angina daily or weekly

− Patients tended to be−Younger−Nonwhite males−Prior CABG or baseline angina− Index hospitalization (recurrent angina)

− Among outpatient variables, patients were more likel y to • Continue smoking• Undergo PCI or CABG after the index hospitalization • Have new, persistent, or transient depression

Angina Prevalence One Year Post-MI

Maddox TM, Reid KJ, Spertus JA, et al. Arch Intern Med. 2008;168:1310-1316

Estimated Direct and Indirect Costs of Major Cardiovascular Diseases and Stroke

2008 Estimates (US$ Billions)

Source: AHA, Heart Disease and Stroke Statistics, 2 008 Update. NHLBIRosamond W, et al. Heart Disease and Stroke Statist ics – 2008 Update. Circulation. 2008;117:e138

CHD; $156,4

HTN; $69,4

Stroke; $65,5

HF; $34,8

Annual Pharmacy Costs in CAD Patients

Kempf J, Shetty S, Nelson M. Resource utilization a nd cost of care for chronic stable angina in the Un ited States. Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke.

May 7-9, 2006 Washington, DC.

The Cost of Chronic AnginaAdapted from Javitz H, et al. Am J Managed Care. 20 04;10(11):S367

Direct Costs 2004 Estimates: $1.9 – $8.9 Billion (US)*

* Direct costs for angina $1.9 billion when it is the first-listed diagnosis and $8.9 billion when it is listed in any position

Trends in Cardiovascular Operations and Procedures (United States: 1979-2005)

0

200

400

600

800

1000

1200

1400

79 80 85 90 95 00 05

Pro

cedu

res

in T

hous

ands

Years

Catheterizations Open-Heart

Bypass PCI

Carotid Endarterectomy Pacemakers


All of us spend far more time

thinking about “how”to best

perform PCI and much less on

“why”, “when”, and “for whom”

The Bottom Line

Stable CAD: PTCA/BMS vs. Medical Rx

Meta-analysis of 11 randomized trials; N = 2,950

Katritsis DG et al. Circulation. 2005;111:2906-12

Adapted from Boden WE, et al. Optimal Medical Therap y with or without PCI for Stable Coronary Disease . N Eng lJ Med 2007;356:1510

COURAGE: Antianginal Medication Use

PCI + Optimal Medical Therapy (21.1%

Revascularization)

Optimal Medical Therapy (32.6% Revascularization)

Baseline 1 y 3 y 5 y Baseline 1 y 3 y 5 y

Continuing Angina (%) 88 34* 28† 26 87 42 33 28

Beta-blockers (%)

85 85 84 85 89 89 86 86

Calcium Channel Blockers (%)

40 40 43 42 43 49 50 52

Long-acting Nitrates (%) 62 53 47 40 72 67 61 57

*p<0.001 for PCI + OMT vs OMT alone.†p=0.02 for PCI + OMT vs OMT alone.

Angina Symptoms Persist in Many Patients Despite Revascularization

Serruys PW, et al. N Engl J Med. 2001;344:1117-1124

Continued angina and antianginal medication use 12 months after revascularization for angina (n=1205)

100%

Stenting groupSurgery group

Pre

vale

nce

(% o

f pat

ient

s)

21%*

79%* 81%*

11%

59% 62%

0%

20%

40%

60%

80%

Continued angina

Continued antianginalmedication

Continued angina and/or antianginal

medication

*p < 0.001

Odds Ratios for Mortality in Individual Trials Comparing the PCI-Based Strategy With Medical

Treatment Strategy

Schomig, A. et al. J Am Coll Cardiol 2008;52:894-904

Ischemia Reduction Improves Outcomes

Shaw, L. J. et al. Circulation 2008;117:1283

Independent Predictors of Early Decision to Revascularize

Countries With High Rates of Angiography – Patients with Stable Angina

Variable OR 95% CI P-Value

Positive exercise ECG 4.05 2.74–6.00 <0.001

Female 0.57 0.37–0.86 0.007

Invasive center 1.62 1.03–2.55 0.04

Symptom duration >6 months 0.66 0.49–0.99 0.04

Daly CA, et al. Eur Heart J. 2005;26:1011-1022

• Majority of the 3,779 patients had been referred by a primary care physician (71%). • Mean age in the survey was 61 years

Angina Costs Managed Health CareKempf J, Shetty S, Nelson M. Resource utilization a nd cost of care for chronic stable angina in the Un ited States.

Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke. May 7-9, 2006 Washington, DC.

Resource Utilization for the Year Following Index D iagnosis (N=171,172)

Objective ischemia predicts benefit of PCI

�Objective evidence of myocardial ischemia is

qualitatively and quantitatively linked to adverse

clinical outcomes

�The degree of myocardial ischemia is directly related

to the magnitude of relative clinical benefit provided by

PCI vs medical Rx

�These findings imply that part of the patients

enrolled in previous trials were unlikely to benefit from

PCI if they had no, or limited myocardial ischaemia and

suggest that functional assessment may help to

identify those who benefit from revascularization

Relationship Between Procedure Indications and

Outcomes of PCI by ACC/AHA Task Force

Class I64%

Class IIa21%

Class IIb7%

Class III8%

Anderson HV et al. Circulation. 2005;112:2786

Incidence of Angina Pectoris by Age and Gender

Framingham Heart Study: 1980/2002-2003


Ricoveri ospedalieri 2010

SDO PATOLOGIA N. RICOVERI

127 Insufficienza cardiaca e shock 203885

87 Edema polmonare acuto 110438

14 Emorragia o infarto cerebrale 91307

125 Mal. CV (non IMA) con CC e senza complicanze 66509

524 TIA 59260

139 Aritmie senza complicanze 57488

143 Dolore toracico 42590

138 Aritmie con complicanze 38192

124 Mal. CV (non IMA) con CC e con complicanze 36426

122 IMA senza complicanze 35093

553 Impianti pacemaker 31683

555 PCI con diagnosi CV maggiore 31076

558 PCI senza diagnosi CV maggiore 29392

1. Abolizione del fumo

2. Controllo della dislipidemia

3. Controllo dei valori pressori

4. Regolare attività fisica

5. Controllo del peso corporeo

6. Gestione del Diabete Mellito

7. Terapia anti-aggregante

8. Terapia con ACE-inibitori/Sartani

9. Terapia beta-bloccante

10. Vaccinazione anti-influenzale

11. Cardiologia Riabilitativa

Circulation. November 29,2011

Noninvasive Risk Stratification

*Although the published data are limited; patients with these findings will probably not be at low risk in the presence of either a high-risk treadmill score or severe resting LV dysfunction (LVEF <35%).

Novità

Prevalenza dell’angina stabile

5.000.000

Coronaropatici

* Popolazione di età compresa tra i 65 e 74 anni

Da 11% a 20%*

Da 10% a 15%*

1.500.000

angina stabile

Ital Heart J 2004; 5 (Suppl 3): 49S-92S

Eur Heart J 2006; 27: 1341-81

Osservatorio Epidemiologico

Cardiovascolare Italiano

Prevalenza dall’angina stabile:

30.000/mllione di ab.

Rosamond W, et al. Heart Disease and Stroke Statistics – 2008 Update.

Circulation. 2008;117:e25-e146.

9.1 milioni di adulti americani

soffrono di angina

Daly C, et al. The impact of guideline compliant medical

therapy on clinical outcome in patients with stable angina:

findings from the Euro Heart Survey of stable angina. Eur

Heart J 2006;27:1298-304.

Circa 10 milioni di adulti europei

soffrono di angina

ACP Clinical Guideline, Ann Intern Med 2004; 141: 562

Likelihood increases according to the presence of

hypertension, smoking, hypercholesterolemia and

diabetes

Pretest likelihood of CAD in symptomatic patients according to

age and sex

Parametri del test associati a coronaropatia e prognosi sfavorevole

� Positività a basso carico

� Spiccato sottoslivellamento di ST (>2mm)

� Sottoslivellamento di ST in più di 5 derivazioni

� Persistenza di anomalie ECG di natura ischemica

per più di 5 minuti nel recupero

� Ridotta capacità di esercizio

� Calo PA sistolica durante sforzo

� Aritmie ventricolari maggiori durante sforzo (TV)


ACC/AHA Guideline, J Am Coll Cardiol, 2003; 41:159

Standard exercise ECG testing is recommended for patients with an intermediate pretest probability of IHD who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity.

I IIa IIb III

Able to Exercise

Kligfied P, Circulation 2006Kligfied P, Circulation 2006

Functional capacity, angiographic coronary disease, and risk for death

in 6213 men referred for treadmill exercise testing for clinical

reasons. Functional capacity is a much more powerful predictor of

death than the presence or absence of obstructive coronary lesions.

Exercise Electrocardiogram Testing:

Beyond the ST Segment

Anti-ischemic Strategies in Ischemic Stable Heart Disease

Initial therapy

Persistent/Recurrent ischemia

↑ Antianginal drug therapy(uptitrate/add additional

agents)

Repeat revascularization (if possible)

Drug therapy PCI CABG

Curiosare tra le raccomandazioni delle nuove linee guida sulla ... · Raccomandazioni dei BB (2006)...

Documents

Transcript of Curiosare tra le raccomandazioni delle nuove linee guida sulla ... · Raccomandazioni dei BB (2006)...